'From Monkeys & Mayhem to Wise Talk & Worry-Free in 3 Visits!'

LAS VEGAS—Even if a patient with chronic pain is doing well with medication and interventional strategies, clinicians need to have some additional, effective nonpharmacologic tools to add to their armamentaria.

That was the premise of this highly interactive workshop at PAINWeek 2014, subtitled, “AKA, ‘From Monkeys & Mayhem to Wise Talk & Worry-Free in 3 Visits!'”

Heidi Allespach, PhD, of the Department of Family Medicine & Community Health at the University of Miami Miller School of Medicine, Miami, Florida has taken four of the most powerful cognitive behavioral pain management interventions and incorporated them into a three-visit model. These four techniques are cognitive restructuring (visit 1), mindfulness exercises (visit 2), and diaphragmatic breathing, and a 6-minute relaxation/imagery exercise (visit 3). All can be done in a regular office visit.

Introduced by Beck, cognitive behavioral therapy (CBT) is the most widely used and studied psychotherapeutic modality in the medical setting. By being both time limited and focused, CBT “helps you and your patients to feel more ‘in control'—and it works, too!,” she said.

In exploring the cognitive-behavioral model, she explained that “the monkey” is “an automatic thought or ‘self-talk' statement that is distorted.” This can include irrational or negative thinking such as anxiety about the future (the “What Ifs?”) as well as depression, guilt, and regrets about the past (the “Would've's, Could've's & Should've's”).

“Remember, ‘we feel what we think,'” she said, adding that “only by becoming aware of ‘the monkey,' can we change the way we feel.” This resonates equally when treating patients with chronic pain, because “only by actively listening to our patient's ‘monkey' will we gain insight into what is going on with them.”

For example, a patient's automatic thoughts can lead to feelings that influence perception of pain. Describing the “wise self” as the opposite of “the monkey,” Dr. Allespach asked, “what can you tell yourself—or what would the ‘wise' part of you tell you—to make you feel less depressed, frustrated, anxious, sad? What would the wise part of you say about the situation?”

Patients can be given cognitive restructuring homework that asks them to become more aware of how their negative thoughts create feelings that increase their pain level and to make a decision to change negative self-talk to more balanced talk.

Also demonstrated was an awareness exercise, which patients can use to “disconnect” from “the monkey” in conjunction with keeping a pain diary; diaphragmatic breathing; and a brief relaxation/imagery exercise.

Dr. Allespach also taught attendees how to weave these nonpharmacologic pain management strategies—which are brief, easy to learn, and are extremely effective—into their practices. She also emphasized that they can immediately begin using these interventions with their patients.